http://www.omicsonline.org/jfrhome.

php

ISSN: 2157-7145

F orensic Research is the

application of a vast and
various spectrums of sciences Jawahar L. Mehta, Todd R. Sandrin, Igor K. Lednev, Iain Matthew McIntyre, Horenstein Moira Batten,
to answer the questions to UAMS and VAMC Little
Rock, USA
New College of
Interdisciplinary Arts and
University at Albany,
USA
Forensic Toxicology
Laboratory, USA
National University of
Cordoba, USA
a legal system. It is a peer Sciences, USA

reviewed journal which aims to

provide the most complete and
reliable information on current
developments in the field of Jaiprakash. shewale, Thomas J. Holt, Oliver Grundmann, Darin T Okuda, Jianye Ge,
forensic science. Life Technologies
Corporation, USA
Michigan State
University, USA
University of Florida,
USA
University of California,
USA
University of North
Texas, USA

Journal of Forensic Research is

an Open Access online journal
which publishes original research
articles and reviews on internet
Scott Douglas Reed, Robin Williams, Howell G.M Edwards, Nicolas Hans Hiroshi Ikegaya,
which are easy to access and American Board of Northumbria University,
UK
University of Bradford, Voelcker, Kyoto Prefectural
University of Medicine
Veterinary, USA UK Flinders University,
freely available.
Kyoto, Japan
Australia

Takaki Ishikawa, Jian Tie, Sheila M Willis, Senta Niederegger, Kaarel Krjutskov,
Osaka City University Nihon University Forensic Science Institute of Legal University of Tartu,
Journal of Forensic Research - Open Access Medical School School of Medicine, Laboratory, Ireland Medicine Jena,
Europe
Japan
using online manuscript submission, review Osaka, Japan Germany

and tracking systems of Editorial Manager®

for quality and quick review processing.

Submit your manuscript at

http://www.omicsonline.org/submission
Xanth Mallett, Itaru Sato, Peter Gill, Yalcin Buyuk, Hajime Utsuno,
University of Dundee, St. Marianna University of The Institute of Forensic Matsumoto Dental
UK University, Japan Strathclyde, UK Medicine of Turkey, University, Japan
Europe

OMICS Publishing Group

5716 Corsa Ave., Suite 110, Westlake, Los Angeles, CA 91362-7354, USA, Phone: +1- 650-268-9744, Fax: +1-650-618-1414, Toll free: +1-800-216-6499
 Forensic
Research
Review Article
The Michael Jackson Autopsy: Insights Provided by a Forensic
Anesthesiologist
Richard J. Levy*
Division of Anesthesiology and Pain Medicine, Children’s National Medical Center, The George Washington University School of Medicine and Health Sciences, USA
Abstract
Based on toxicology findings performed on samples taken at the time of autopsy, the cause of Michael Jackson’s
death was determined to be acute propofol intoxication with a contributory benzodiazepine effect. The manner of
death was determined by the coroner to be homicide. At the center of this case are several anesthetic medications.
Insight into the toxicology, review the autopsy results, and summary of the findings are provided from a forensic
anesthesiologist’s point of view.
Introduction
Michael Jackson was pronounced dead on June 25, 2009 at 2:26
pm in the afternoon at UCLA Medical Center. He died despite two
and a half hours of attempted cardiopulmonary resuscitation (CPR).
At 12:22 pm, roughly thirty minutes after the 911 call from Mr.
Jackson’s residence, paramedics found the pop star unresponsive and
asystolic.They placed an endotracheal tube in his airway, began chest
compressions, and administered epinephrine.Spontaneous circulation
was never restored. Mr. Jackson remained unconscious with fixed and
dilated pupils. At the direction of Mr. Jackson’s physician, Dr. Conrad
Murray, the decedent was taken by ambulance to UCLA Medical
Center while CPR efforts continued.
When they arrived at the hospital, Mr. Jackson remained asystolic.
Emergency room physicians placed three central venous catheters and
an arterial balloon pump within his aorta in order to attempt to restore
coronary perfusion. Death was officially pronounced at 2:26 pm and
was immediately reported to the Los Angeles County Department of
Coroner. The death investigation began at 5:20 pm on June 25, 2009.
Michael Jackson’s autopsy was performed on June 26, 2009 at 10:00
am. Based on toxicology findings, the cause of his death was determined
to be acute propofol intoxication with a contributory benzodiazepine
effect. The manner of death was determined by the coroner to be
homicide.Michael Jackson’s personal physician, Dr. Conrad Murray,
was charged with involuntary manslaughter; a felony.
On July 22, 2009, a search warrant was issued for the search and
seizure of several items from Dr. Murray’s self storage unit in Harris
County, Texas. The sworn affidavit provided by Detective Orlando
Martinez of the Los Angeles Police Department was included in
the search warrant to indicate probable cause [1]. The details of the
events of June 25, 2009 and the days leading up to that fateful day
are detailed in this affidavit. On February 8, 2010, The Smoking Gun
posted the death investigation and autopsy findings [2]. It revealed
post-mortem details of Michael Jackson’s medical conditions and the
toxicologic evidence trail of an accidental death. At the center of this
case are several anesthetic medications. The trial will focus on two
potential scenarios. The prosecution will aim to show that Dr. Murray
administered the propofol that killed Mr. Jackson and the defense will
argue that Mr. Jackson administered propofol to himself. As a forensic
anesthesiologist, I will provide insight into the toxicology, review
the autopsy results from a clinician’s point of view, and interpret the
findings.
J Forensic Res
ISSN: 2157-7145 JFR, an open access journal
Levy, J Forensic Res 2011, 2:8
http://dx.doi.org/10.4172/2157-7145.1000138
Open Access
The medical findings
Michael Jackson was a 50 year old man. His autopsy demonstrated
that he suffered from many common medical conditions. Although
none of these illness and findings contributed to his death, they are of
interest from a medical curiosity standpoint.
Genitourinary system
Michael Jackson’s autopsy demonstrated that he had nodular
prostatic hyperplasia. The prostate gland is part of the male
reproductive system and the urethra courses through it. When the
prostate enlarges, it can constrict the urethra and impede the flow of
urine. Such constriction makes initiating the urine stream difficult,
results in weak flow, dribbling after urination, the feeling that the
bladder is not completely empty, urgency, and frequency [3]. About
50% of all men over the age of 75 will have some of these symptoms [3].
On autopsy, Mr. Jackson’s bladder was distended and filled with urine.
In life, his enlarged prostate would have resulted in urinary retention
and difficulty voiding. At autopsy, a condom-type urinary catheter
was found on his genitals. At the time of his death, Jackson was being
treated with tamsulosin to alleviate his urinary symptoms.Tamsulosin
is an alpha receptor antagonist which relaxes the prostate and alleviates
the constriction on the urethra [3].
Gastrointestinal system
Examination of Michael Jackson’s gastrointestinal system
revealed a 2 mm pedunculated polyp in his sigmoid colon. Histologic
evaluation of the polyp identified it as a tubular adenoma. This type of
polyp accounts for about 75% of all colon polyps and can potentially
become malignant if left untreated [4]. It is likely that Mr. Jackson
had no symptoms from this and had no knowledge of it. A routine
colonoscopy would have identified the polyp and permitted biopsy and
*Corresponding author: Levy at Division of Anesthesiology and Pain Medicine,
Children’s National Medical Center, 111 Michigan Ave., NW, Washington, DC USA
20010, Tel: (202) 476-2025; Fax: (202) 476-4922; E-mail: rlevy@cnmc.org
Received July 10, 2011; Accepted October 24, 2011; Published October 26,
2011
Citation: Levy RJ (2011) The Michael Jackson Autopsy:Insights Provided by a
Forensic Anesthesiologist. J Forensic Res 2:138. doi:10.4172/2157-7145.1000138
Copyright: © 2011 Levy RJ. This is an open-access article distributed under the
terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and
source are credited.
Volume 2 • Issue 8 • 1000138
Citation: Levy RJ (2011) The Michael Jackson Autopsy:Insights Provided by a Forensic Anesthesiologist. J Forensic Res 2:138. doi:10.4172/2157-
7145.1000138
removal. The American Cancer Society recommends routine screening
colonoscopy beginning at age 50 for both men and women [4]. Follow
up evaluations depend on whether or not polyps and malignancies are
detected.
Skeletal system
Several x-rays were taken of Mr. Jackson’s skeletal system. He had
mild degenerative spondylosis of the lower thoracic spine and suffered
from degenerative osteoarthritis in several joints including his lower
lumbar spine and digits. He also was found to have a small cervical rib
on the second to last cervical vertebrae on the right side of his neck
(C7). Cervical ribs occur in 5-10% of the population and they can cause
thoracic outlet syndrome [5]. It is unknown if Michael Jackson suffered
symptoms from his cervical rib.Thoracic outlet syndrome results when
the rib compresses or traps the brachial plexus and the subclavian
artery that supply the ipsilateral hand and arm [5].Such compression
often results in sharp, burning or aching pain as well as numbness,
weakness, and parasthesias in the affected arm.
Pulmonary system
Microscopic examination of Michael Jackson’s lungs revealed
impressive and long standing abnormalities. Both lungs were
markedly inflamed with bronchiolits, chronic interstitial pneumonitis,
eosinophilic infiltrates, and there was evidence of fibrocollagenous
scarring. In addition, there was widespread congestion in both lungs
and patchy areas of hemorrhage. Furthermore, two small arteries
had organizing and recanalizing thromboemboli. This means that
the arteries clotted off in the past and were in the early stages of
re-establishing blood flow. There was also evidence of histiocytic
desquamation and focal desquamation of the respiratory lining with
squamous metaplasia. This means that cells were sloughing off of the
inner lining of his airways within each lung and there was a change
in cell type. These findings are very abnormal. In life, such pathology
could cause shortness of breath and difficulty breathing as well as a
chronic cough. Michael Jackson’s lung pathology would have made it
difficult for him exert himself physically and probably caused him to
fatigue easily.
Teeth, Skin, and Hair
Dental examination revealed a root canal along with endosseal
implants and metallic and ceramic restoration of many different
teeth. His skin demonstrated patches of dark pigmented and lighter
less pigmented areas consistent with vitiligo. Mr. Jackson also had
dark tattoos in his eyebrows and had tattooed his eyelids to look like
eyeliner. He also had tattooed both of his lips pink. He was wearing a
black wig kept in place by an adhesive substance. Underneath the wig,
his own hair was short and tightly curled with frontal balding. Hair
loss could have been the result of the incident in which Mr. Jackson’s
hair caught fire during the 1984 filming of a cola commercial. He had
several surgical scars around the face and neck likely from prior plastic
surgical procedures.
A Serious Medical Diagnosis
The combination of vitiligo, arthritis, and lung inflammation
raises the concern for an autoimmune disease. In fact, in 1986,
Michael Jackson was diagnosed with systemic lupus erythematosus
(SLE). SLE is a serious and potentially life threatening disease that can
occur at any age [6]. It affects women more commonly than men and
African Americans and Asians more commonly than other races [6].
Symptoms vary widely and often flare or go into remission frequently.
J Forensic Res
ISSN: 2157-7145 JFR, an open access journal
Page 2 of 7
Common symptoms include chest pain, fatigue, fever, hair loss, skin
rash, swollen lymph nodes, sensitivity to sunlight, and mouth sores [6].
Complications from SLE include thrombosis, hemolysis, pleural and
pericardial effusions, stroke, and vasculitis [6]. There is no cure for SLE
and treatment usually consists of ant-inflammatory medications and
steroids. Although Michael Jackson had received treatment for lupus
in the past, he was not on any such therapy at the time of his death.
His SLE was reportedly in remission, however, the pulmonary findings
suggest that it had caused significant lung injury.
Although none of the medical findings in Michael Jackson’s
autopsy contributed to his death, they certainly indicate that the singer
suffered from both SLE and prostatic hyperplasia.
The Death Investigation
Witness statements: On June 27, 2009, a detective from the Los
Angeles Police Department interviewed Dr. Murray in the presence of
his attorneys. Murray provided the following information.
Dr. Murray, a cardiologist, began treating Michael Jackson as his
personal physician for insomnia six weeks prior to June 25, 2009. Each
evening, he would administer propofol mixed with lidocaine to Mr.
Jackson. Murray stated that he injected Mr. Jackson with 50 mg of
propofol via an intravenous catheter (iv). The lidocaine was added in
an attempt to prevent the painful stinging sensation associated with
propofol injection. Dr. Murray stated that, at the time, he believed
Mr. Jackson was developing an addiction to propofol. In the days
prior to Mr. Jackson’s death, Murray attempted to wean him off
of the anesthetic. On June 22, 2009, Murray administered 25 mg of
propofol, lorazepam (a long acting benzodiazepine), and midazolam
(a short acting benzodiazepine) to Michael Jackson. On June 23, 2009,
Murray only gave Mr. Jackson lorazepam and midazolam and did not
inject propofol. At 1:00 am on June 25, 2009, Michael Jackson called
Dr. Murray, complaining of dehydration and insomnia. At 1:30 am,
Murray gave Mr. Jackson a 10 mg tablet of diazepam (a long acting
benzodiazepine). This did not help Mr. Jackson fall asleep. Murray
then injected 2 mg of lorazepam thirty minutes later. Dr. Murray
stated that he was monitoring Michael by using a pulse oximeter
connected to Jackson’s finger. This device measures oxygen saturation
in the blood and is a standard of care when administering sedatives in
a variety of clinical settings. At 3:00 am, Murray gave Mr. Jackson 2
mg of midazolam. Mr. Jackson remained awake. Murray then gave a
subsequent 2 mg dose of lorazepam at 5:00 am. At 7:30 am, Dr. Murray
injected Michael with 2 mg of midazolam. Mr. Jackson remained
awake and repeatedly asked for and demanded a propofol injection.
At 10:40 am, Murray injected 25 mg of propofol mixed with lidocaine.
According to Murray, Mr. Jackson finally fell asleep. Dr. Murray then
left the bedroom to use the restroom. He stated that he was away from
Mr. Jackson for no more than 2 minutes. Upon his return, Michael
Jackson was unconscious and apneic. In the interview, Murray did not
mention what Mr. Jackson’s oxygen saturation was at the time or if the
monitor had been alarming. He then pulled Mr. Jackson’s body onto
the bedroom floor and initiated CPR by himself. Murray stated that,
at this time, he gave 0.2 mg of flumazenil (a benzodiazepine reversal
agent) to try to reverse the effect of the lorazepam and midazolam. He
called Mr. Jackson’s security detail by cell phone for help. They did not
respond. Murray then stopped CPR, left Michael Jackson’s bedside,
and ran downstairs to ask Jackson’s chef to send Jackson’s eldest son in
to help him. When Murray returned, he continued CPR. It is unclear
how long he was gone for. The security detail finally arrived shortly
after and called 911.
Volume 2 • Issue 8 • 1000138
Citation: Levy RJ (2011) The Michael Jackson Autopsy:Insights Provided by a Forensic Anesthesiologist. J Forensic Res 2:138. doi:10.4172/2157-
7145.1000138
Murray told investigators that he was not the first doctor to
administer the anesthetic, propofol to Michael Jackson. According
to Murray, Mr. Jackson admitted that two doctors in Germany had
previously administered Jackson the drug. In addition, in March or
April of 2009, Mr. Jackson convinced Murray to arrange for an office
based anesthesiologist to administer propofol to Jackson. In January
of 2009, Michael Jackson met a nurse practitioner who was providing
care for his three children. Mr. Jackson told her that he was fatigued.
She diagnosed him with borderline-hypoglycemia. She placed Michael
on a nutritional diet with a supplemental protein drink. On April 12,
2009, Mr. Jackson visited the nurse practitioner again and complained
of insomnia. He asked if she was familiar with the drug propofol. She
was not. Michael tried to convince her that it was safe. The practitioner
subsequently read about propofol and warned Mr. Jackson not to
take the medication. Michael then asked if she could obtain some
propofol or if she knew of someone who could. According to the nurse
practitioner, Mr. Jackson offered to pay her or anyone else whatever
they wanted in exchange for it. She refused and that was the last time
she saw Michael Jackson.
The death scene
Investigators went to Michael Jackson’s 2-story mansion in the Bel-
Air section of Los Angeles at 7:10 pm on June 25, 2009. They found
the home to be clean and in order. They went directly to second floor
bedroom where Dr. Murray was administering care to Mr. Jackson.
The room was furnished with a queen sized bed, several tables and
chairs, a dresser, and a television. The bed was in disarray. On the bed,
there was an impression in the sheets where Michael Jackson slept and
a blue pad was present (in case of accidental voiding). Near the foot of
the bed, there was a tube of toothpaste, a string of beads, and a bottle of
urine. On the other side of the bed, there was a book, a pair of glasses,
and a laptop computer. Several empty orange juice bottles were on a
nearby table. An oxygen tank rested on the side of the bed. This tank
was empty when examined on July 13, 2009. A self-inflating ventilation
bag along with face mask (that was not attached to the oxygen tank) was
found near where Mr. Jackson received CPR along with latex gloves,
disposable needles, alcohol pads, and a box of iv catheters. There was
no mention of a pulse oximeter monitor at the scene. It is unknown if
the emergency responders brought the oxygen tank and ventilation bag
or if these were Dr. Murray’s.
An iv fluid setup was found consisting of a 1-liter bag of clear fluid,
connection tubing, and a short Y-connector. A short section of iv
tubing attached to the Y-connector contained yellow tinted fluid. Two
10 mL syringes with some residual white fluid and multiple opened
bottles of propofol were also found. Eight bottles of propofol in all
were recovered. The iv setup and syringes were collected as evidence.
Multiple vials of lidocaine, lorazepam, midazolam, and flumazenil
were also found. Several bottles of prescription pills were in the
home. These medications included clonazepam, trazodone, diazepam,
lorazepam, tamsulosin, temazepam, and tizanidine. The diazepam,
tamsulosin, lorazepam, and temazepam were prescribed by Dr.
Murray, the clonazepam and trazodone were prescribed by a different
general practitioner, and the tizanidine was prescribed by Jackson’s
dermatologist. Each of these medications, except for the tamsulosin,
was prescribed to treat insomnia.
The witness accounts indicate that Michael Jackson craved propofol
and demonstrated drug seeking behavior. His pattern of visiting various
different physicians and medical caregivers in order to obtain propofol
J Forensic Res
ISSN: 2157-7145 JFR, an open access journal
Page 3 of 7
and other prescription sleep-aids is a clear example “doctor shopping”.
When a particular caregiver refuses or ceases to give a patient the
medication they are seeking, they simply try to find another caregiver
that will. It is common for such patients to reach out to several different
medical providers in a variety of different specialties. These actions are
classic drug addiction behavior.
The Autopsy and Toxicology
The external examination of Michael Jackson at the time of autopsy
revealed gauze pads on the right side of his neck, in the antecubital
region of his left and right arms, and on his left forearm. These were
presumably sites where placement of iv catheters during CPR was
attempted. Three large central venous catheters were in place: one in his
left jugular vein and one in each femoral vein. An arterial balloon pump
was in the appropriate position within the aorta through the left femoral
artery and an endotracheal tube was present within the decedent’s
airway. These had been successfully placed by the Emergency Room
team at UCLA Medical Center during the resuscitation. In the center
of his chest, Mr. Jackson had a large bruise and abrasion. His sternum
and several ribs were fractured. These were undoubtedly as a result
of chest compressions during CPR. There were also several puncture
sites in both arms, one on his left knee and one on his right ankle. It is
unclear if any of these represented sites where intravenous medications
were administered by Dr. Murray. The anesthesiology consultant for
the case stated that an iv catheter was noted in Mr. Jackson’s left leg,
however, the autopsy report did not mention such a catheter.
Of note, the blood within Michael Jackson’s heart was unclotted
at the time of autopsy. The autopsy was performed on June 26, 2009 at
10:00 am; roughly 20 hours after the time of death. Finding unclotted
blood at the time of autopsy is consistent with hypoxia. This is often seen
in cases of asphyxia and sudden infant death syndrome, for example
[7]. It suggests that Mr. Jackson was apneic prior to his death, resulting
in a critical decline in oxygen saturation and subsequent asystole.
Toxicology was performed by the coroner’s office on Michael
Jackson’s blood (samples drawn at UCLA Medical Center and at the
time of autopsy), vitreous, liver, stomach contents, and urine (the
bottle collected at the scene and taken from his bladder during the
autopsy). In addition, tests were performed on the 10 mL syringes and
iv fluid setup and tubing. These results were critical to determining the
cause of Michael Jackson’s death (table). Propofol was detected in his
blood, vitreous, liver, stomach contents, and in both urine samples.
The levels of propofol found in each sample of blood were within the
therapeutic range. This means that there was enough propofol in his
system at the time of death to render him unconscious.Lidocaine was
also detected in each specimen except for the vitreous. Three different
benzodiazepines along with a metabolite of diazepam (nordiazepine)
were detected in Mr. Jackson’s blood. Midazolam was also present in
his urine. These findings indicate that Michael had either taken or was
given diazepam, lorazepam, and midazolam within hours prior to his
death. Ephedrine was detected in the two urine samples.
The two 10 mL syringes found at the scene each contained a small
amount of white fluid (0.19 grams and 0.17 grams). Propofol and
lidocaine were detected in one syringe and propofol, lidocaine, and
flumazenil were detected in the other. The short section of iv tubing
attached to the Y-connector that contained yellow tinted fluid was tested
and was also found to contain propofol, lidocaine, and flumazenil. No
drugs were detected in the rest of the intravenous tubing or 1-liter bag
with clear fluid. These fluids were presumably saline or some other
routine medical delivery solution.
Volume 2 • Issue 8 • 1000138
Citation: Levy RJ (2011) The Michael Jackson Autopsy:Insights Provided by a Forensic Anesthesiologist. J Forensic Res 2:138. doi:10.4172/2157-
7145.1000138
In order for an accurate interpretation, it is important to review
some important pharmacologic properties of propofol.
Propfol
Propofol is a potent anesthetic drug that rapidly causes sedation
and unconsciousness when intravenously injected [8,9]. Since 1986,
it has been used world-wide in clinical settings and has become the
anesthesiologist’s drug of choice to induce general anesthesia and
to provide sedation for a variety of procedures [9,10]. Propofol is
administered as a single injection to induce unconsciousness or as a
continuous infusion to maintain a desired level of sedation [11]. It is a
very short acting drug and patients rapidly awaken following injection
if an infusion is not initiated [11].
In 2009, propofol was not a controlled substance scheduled by the
U.S. Drug Enforcement Agency. However, today, the drug is in the
process of being reclassified. Hospitals usually have policies to restrict
propofol use to specific areas within the hospital and limit those capable
of administering it to qualified personnel such as anesthesiologists and
critical care physicians. In addition to being clinically indicated for
anesthesia and sedation, propofol has also been used to treat seizures,
migraine and tension headaches, severe alcohol withdrawal and
delirium tremens, and has been used to facilitate narcotic detoxification
[8,11]. It has never been indicated to treat insomnia.
Propofol is insoluble in water and the current formulation is
an emulsion of soybean oil, glycerol, and egg lecithin. This lipid
formula gives the drug its characteristic and unique white color [8].
In his interview with investigators, Dr. Murray told investigators that
Michael Jackson craved propofol and called it “his milk” (because of the
white color). Certain preparations of propofol will turn yellow when
exposed to air for 6 to 7 hours. Propofol causes a burning pain when
it is injected, so many anesthesiologists will attempt to anesthetize
the vein with lidocaine, a local anesthetic. This can be done either by
injecting lidocaine into the vein prior to propofol administration or by
mixing lidocaine with propofol in the syringe. According to Murray,
Mr. Jackson was well-versed in the use of lidocaine to limit or prevent
propofol’s pain on injection.
Propofol induces unconsciousness rapidly. Loss of consciousness
occurs 100 seconds following a 2.5 mg per kilogram injection and
lasts for 5-10 minutes [8]. It blunts the respiratory drive and relaxes
oropharyngeal muscle tone, potentially resulting in airway obstruction.
Without proper management by an experienced provider, a single
injection of propofol can result in apnea, hypoxia, and death [8].
Furthermore, injection of 2.5 mg per kilogram results in a 25-40%
reduction in blood pressure [8]. This decrease in blood pressure is
more pronounced in dehydrated patients. These effects make propofol
potentially dangerous and lethal when injected by inexperienced
personnel or self administered. Following injection, propofol is rapidly
eliminated by the body. It is metabolized in the liver and excreted into
the urine by the kidneys [8]. Thus, propofol does not accumulate in
the body.
The abuse potential of propofol was not recognized until 1992.
Since then, 38 cases of propofol abuse have been published [10].
Propofol has increasingly become a drug of abuse largely because it
is easily accessible, it has a rapid onset of action, and the duration
of action is ultra-short without long term side effects [10].Medical
professionals and healthcare workers represent the largest group of
known propofol abusers [10]. Of these personnel, anesthesiologists
and nurse anesthetists are the most common offenders. The most likely
J Forensic Res
ISSN: 2157-7145 JFR, an open access journal
Page 4 of 7
rationale for this is familiarity with the drug and previously unregulated
access to it. Recent studies suggest that propofol diversion and abuse
are on the rise [12].
The majority of cases of propofol abuse involve use of the drug for
recreational purposes, stress relief, and to alleviate insomnia. In one
report, propofol dependency was described in a lay person following
a propofol prescription for the treatment of tension headaches [11].
The average age of known propofol abusers is about 30 years of age
and most abusers are male [13]. In most cases, propofol was used in
addition to other drugs of abuse and the user had a history of drug
dependency [13].
Physical dependence has not been described in propofol abusers,
however, psychological dependence is quite common [10,13]. This is
because propofol can cause euphoria, stress and tension relief, sexual
fantasies and dreams, and sexual disinhibition [10,13]. These effects
of propofol lead to drug craving and loss of control over the amount
and frequency of drug injected as well as continued use of propofol
despite adverse consequences. Chronic propofol abuse can result in
tolerance and repeated injections exceeding 100 times per day have
been reported [14].
Propofol abuse and recreational use often result in death because
of the rapid onset of unconsciousness and apnea following injection
[10]. Thirty-seven percent of the 38 published cases of abuse were
fatal [10]. The majority of these propofol related deaths resulted from
accidental overdose or suicide. Recently, the first case of first degree
murder with propofol was reported [10].
Blood levels of propofol in most propofol related deaths are
usually within the therapeutic range (1.3 – 6.8 μg/mL). This means that
propofol induced unconsciousness and the cause of death was likely
due to apnea with subsequent hypoxia. As with other drugs of abuse, a
specific “lethal level” may not be necessary to conclude that death was
caused by propofol injection. Simply detecting it in blood indicates it
was injected prior to death and at least contributed to if not caused the
death.
Several accidental propofol related deaths have been reported. A 26
year old male ICU nurse who was a known propofol abuser was found
dead in his apartment surrounded by several empty and partially empty
propofol vials along with two syringes [15]. His autopsy demonstrated
several recent and partially scarred needle marks on his arms, wrists,
and hands. Propofol was detected in his hair, blood, urine, brain, and
liver.
A 27 year old male nurse anesthetist was found dead at his home
with three empty propofol vials next to him [16]. Unopened propofol
bottles were found in his car. Several needle marks in his skin suggested
chronic abuse. His autopsy revealed pulmonary hemorrhage and
inflammation of the pancreas. Propofol was detected in his blood, bile,
and urine.
A 44 year old female nurse anesthetist was found dead at her home
with an empty vial of midazolam and a syringe near her body [17].
Toxicology revealed propofol, midazolam, and alcohol in her blood.
Analysis of her hair demonstrated propofol and midazolam in several
segments indicating repetitive abuse for 6 months prior to her death.
A 21 year old male lay person purchased propofol online using
an internet bidding system [18]. He was found with an iv catheter in
situ that he had placed in order to inject propofol several times a day.
Propofol was detected in his blood.
Volume 2 • Issue 8 • 1000138
Citation: Levy RJ (2011) The Michael Jackson Autopsy:Insights Provided by a Forensic Anesthesiologist. J Forensic Res 2:138. doi:10.4172/2157-
7145.1000138
A 38 year old known propofol abusing female anesthesiologist was
found dead in a hospital on call room [19]. She was kneeling on the
floor facing downward with three empty vials of propofol and two used
syringes next to her. Autopsy demonstrated numerous needle marks
with recent and older hemorrhages in both arms, two iv catheters
secured in each wrist, and pulmonary edema. Propofol was detected
in her blood.
Seven other accidental propofol related deaths have been reported
in members of anesthesiology residency programs [10]. Six of the
victims were anesthesiology residents and one was an anesthesia
technician. All were propofol abusers.
Two suicides have also been reported in which propofol was used to
operationalize the plan. In the first case, a 29 year old female radiologist
committed suicide by self-administering propofol [20]. Propofol was
detected in her blood and liver.
In another case, a 37 year old male medical doctor committed
suicide with propofol after he recently broke off an extra-marital affair
[21]. He was found dead, lying on his back on the bed of a rented room.
Two needles had been inserted into the dorsum of his left and right
hands. Each was attached to an iv fluid delivery system. Eight empty
propofol vials were found at the scene. His body was moderately
decomposed and autopsy findings were fairly unremarkable. Propofol
was detected in his blood, liver, kidney, and brain. It was calculated that
he self-administered about 1600 mg of propofol. Of note, Dr. Murray
claimed that he only gave Michael Jackson 25 mg of propofol the day
he died.
To date, there has only been one case of murder by propofol
injection [10]. The details are as follows. A 24 year old University of
Florida student was found dead in her house in 2005 near Gainesville.
Syringes, needles, and 2 empty propofol vials were found in grocery
store bags outside of her house next to her garbage cans. Autopsy
demonstrated a pinpoint puncture wound in the crease of her left
elbow with hemorrhage directly over a superficial vein. Toxicology
assessment detected propofol in her blood. The medical examiner
concluded that the woman’s death was homicide caused by a lethal
dose of propofol administered by a person skilled in iv injection.
Investigation of the propofol bottle lot numbers found at the
crime scene indicated that the vials were obtained from a University of
Florida hospital. Upon further investigation it was determined that the
propofol bottles had been removed from the hospital by a male ICU
nurse. He had acquired the propofol approximately 5 to 6 days prior
to the murder.
Thorough questioning of the nurse’s former roommate revealed
important details and a potential motive. The roommate had previously
introduced the nurse to the victim. The male nurse soon became
infatuated and obsessed with the victim. After learning that the victim
had gotten engaged to her boyfriend of 4 years, the nurse became
enraged and planned to kill her. Detectives learned that the victim
suffered from chronic migraine headaches. She apparently trusted the
nurse and he convinced her that he would relieve her symptoms with
propofol. One week after her engagement, the male nurse injected the
victim with the lethal dose of propofol.
The nurse left the country and a few weeks later he was apprehended
in the West African Republic of Senegal. He was escorted to the
Alachua County Department of the Jail by the US Marshall’s Service
J Forensic Res
ISSN: 2157-7145 JFR, an open access journal
Page 5 of 7
and was ultimately tried and convicted of first degree murder. He was
sentenced to life in prison without parole.
Jackson’s death has also been determined to be a homicide. This is
because the coroner concluded that:
1. Propofol and benzodiazepines were administered by another
person.
2. Propofol was injected in a non-hospital setting without
appropriate medical indication.
3. The standard of care for administering propofol was not met.
4. There was no evidence that Michael Jackson administered
propofol to himself.
The prosecution’s case will hinge on the evidence that Dr. Murray
administered the medications to Mr. Jackson. The defense will try
to demonstrate that Mr. Jackson may have possibly administered
propofol to himself prior to his death. Is this a homicide, suicide, or
accidental death?
Whodunnit?
The prosecution’s scenario: Dr. Murray administered
benzodiazepines and propofol mixed with lidocaine to Michael Jackson
in the pop star’s bedroom. After Mr. Jackson lost consciousness,
Murray left his patient to go to the bathroom. During the time that
Murray was out of the room, Michael either became apneic or his
airway became obstructed. He soon became hypoxic and asystolic.
When Murray returned to the bedside, he recognized that Mr. Jackson
was not breathing. He drew up flumazenil in the same syringe that
previously had propofol and lidocaine in it and injected the medication
to try to reverse the benzodiazepine effect. Nothing happened. Murray
then began CPR.
Evidence that supports this theory is Murray’s own testimony.
He admitted that he gave Mr. Jackson benzodiazepines and propofol
with lidocaine. The objective evidence that supports the prosecution’s
theory is that the amounts of propofol, lidocaine, and benzodiazepines
in Michael Jackson’s blood confirm that these medications were given
in the hours prior to death. Furthermore, the amount of propofol in the
blood was within the therapeutic range. Thus, it is likely that propofol
caused apnea or an obstructed airway.
There is a problem with this version of the story, though. Dr. Murray
stated that he only administered 25 mg of propofol to Mr. Jackson.
At the time of death, Michael weighed approximately 60 kilograms.
The 25 mg dose, less than 0.5 milligrams per kilogram, is incredibly
small. Although some patients may have a mild sedative effect from
this propofol dose, they would not become unconscious unless there
were extremely hypovolemic or had significant cardiac dysfunction.
Jackson had neither of these conditions. Also, this small dose of
propofol would not result in the blood levels that were detected in the
toxologic analysis. Furthermore, since Michael was receiving propofol
almost every night, he would have likely developed some tolerance to
the drug. So, something doesn’t add up. The prosecution would say that
Dr. Murray is not being truthful about the dose of propofol he used. He
must have administered more. The total injected dose was probably in
the 120 mg to 180 mg range (2-3 mg per kilogram).
The lidocaine concentrations found in the blood are consistent
with a 2 mg per kilogram injection about one hour prior to Michael’s
death [22]. Most anesthesiologists combine 40 mg of lidocaine with
Volume 2 • Issue 8 • 1000138
Citation: Levy RJ (2011) The Michael Jackson Autopsy:Insights Provided by a Forensic Anesthesiologist. J Forensic Res 2:138. doi:10.4172/2157-
7145.1000138
Drug Heart blood Hospital blood Femoral blood Vitreous Liver
Propofol 3.2 4.1 2.6 <0.40 6.2
Lidocaine 0.68 0.51 0.84 - 0.45
Diazepam <0.10 present - - - -
Nordiazepam <0.05 - - - -
Lorazepam 0.162 - 0.169 - -
Midazolam 0.0046 - - - -
Ephedrine ND - - - -
Levels are presented in μg per mL or μg per gram. mL; milliliters, mg; milligrams, ND; not detected.
Table 1: Summary of Toxicology Findings.
180 mg of propofol in a syringe when they mix the two for injection.
The toxicology suggests that Michael received between 60 and 120 mg
of intravenous lidocaine. Depending on how Murray mixed the two
drugs, if he had only given 25 mg of propofol, then he would have only
given about 5.5 mg of lidocaine. This would have been barely detectable
in the blood. On the other hand, an intravenous injection of 60 mg of
lidocaine equates to a dose of roughly 270 mg of propofol (more than
5 mg per kilogram) when using a standard lidocaine/propofol mixture.
Such a dose of propofol would have been more than adequate induce
unconsciousness and apnea.
The defense’s scenario: Dr. Murray administered benzodiazepines
and propofol mixed with lidocaine to Michael Jackson in the pop star’s
bedroom. After Mr. Jackson fell asleep, Murray went to the bathroom.
During the time that Murray was out of the room, Michael Jackson, in
a semi-awake state, administered the lethal dose of propofol to himself.
He either injected propofol into his iv catheter himself, attempted to
drink propofol, or both. The defense is essentially arguing that Mr.
Jackson’s death was an accidental death caused by his own actions.
What is the evidence to support this theory? First, the blood levels
of propofol would certainly reflect a potentially lethal dose of propofol
regardless of who injected it. Could Michael Jackson have injected
propofol into his own vein? It may be possible. He had seen the
procedure enough times in the past so that he would have understood
the logistics. The anesthesiology consultant to the coroner stated that,
because the injection port in the iv tubing setup was 13.5 cm from the
tip of the iv catheter in his left leg, self-injection would be awkward and
unlikely. The consultant never stated that it was impossible.
How about ingestion of propofol as a contributor? The evidence to
support this is that his stomach contents contained both propofol and
lidocaine. The only way these drugs could have entered his stomach prior
to death is if they were ingested. Only 0.13 mg of propofol was detected
in the 70 mL of stomach contents. This is an extremely small amount
of propofol. However, the fact that both drugs were detected indicates
that they came from the same syringe in which both medications were
mixed. Proving that Michael Jackson injected himself with propofol or
drank from the syringe is very difficult. One possible technique would
have been to perform fingerprint analysis on the propofol bottles and
syringes. Certainly, finding the decedent’s fingerprints on the syringes
would not rule out the possibility that he handled these earlier in the
day or that someone placed them in his hands after he died. However,
to my knowledge, fingerprint analysis was never done.
The defense will argue that oral ingestion of propofol can result in
sedation and unconsciousness. What is the evidence? There are only
two related publications on the matter. In the first study, propofol
absorption via rectal suppository (55 mg per kilogram) in 6 week old
piglets was evaluated [23]. None of the piglets became sedated with
J Forensic Res
ISSN: 2157-7145 JFR, an open access journal
Page 6 of 7
Stomach contents (in 70 mL) Urine Urine at the scene
0.13 mg 0.15 <0.10
1.6 mg present present
- -
- - -
- - -
- 0.0068 0.025
- present present
rectal propofol and blood levels of propofol were 100-fold lower than
those achieved following intravenous injection. The second relevant
study assessed propofol absorption following oral administration
in rats [24]. In this work, propofol was shown to undergo extensive
metabolism in the intestine and only 10% of the ingested dose reached
the circulation. As with rectal absorption, the resultant blood levels
of propofol following oral administration were 100 times less than
parenteral injection. Thus, in order to become unconscious from
propofol ingestion, Michael Jackson would have had to drink about
12,000 mg of propofol (over 1-liter in volume). This is a very unlikely
scenario.
It is possible, however, that Mr. Jackson attempted to drink the
drug. Furthermore, one cannot rule out the possibility that he may
have intravenously administered propofol himself. Another scenario
is that someone else may have deliberately injected the contents of a
syringe of propofol into the decedent’s esophagus in the peri-mortem
period to make it appear as if Mr. Jackson ingested the drug. This
would imply that the person: 1. knew that the coroner would check
stomach contents for medications, 2. knew that finding propofol in the
stomach would provide an alibi, and 3. attempted to divert blame to
the decedent.
Neither of these scenarios addresses the ephedrine in Mr. Jackson’s
urine or why flumazenil was detected in the same syringe as propofol and
lidocaine. Ephedrine is a stimulant. In the US, ephedrine is controlled
by the FDA and they have put strict limits on maximum daily dosage.
It is unknown how ephedrine was taken by or administered to Mr.
Jackson. It is quite possible that he was using this stimulant to help him
work through exhaustion and lethargy as he prepared for his upcoming
concert tour. Of note, patients who take or receive ephedrine while
taking serotonin-reuptake inhibitors, such as trazodone, could have
a fatal reaction (Michael Jackson was taking trazodone). Since there
was no ephedrine detected in the decedent’s blood, it played no role in
his death and was not given to him that evening. So it is unclear how
ephedrine fits in to the story.
Flumazenil is a pharmacologic agent used to reverse the effects
of benzodiazepines. It is strictly avoided in patients who have been
chronically taking benzodiazepines because it can result in seizures,
withdrawal, or life threatening arrhythmias. Thus, it is would have been
contraindicated for Mr. Jackson. Furthermore, if a clinician wanted to
reverse the sedative effect of benzodiazepines, they certainly would
not inject flumazenil along with propofol. This is because additional
propofol administration would only deepen the level of sedation
and would antagonize the situation. Finding flumazenil mixed with
propofol likely indicates that Dr. Murray hurriedly prepared the
reversal agent in a syringe that he had previously used for propofol
injection.
Volume 2 • Issue 8 • 1000138
Citation: Levy RJ (2011) The Michael Jackson Autopsy:Insights Provided by a Forensic Anesthesiologist. J Forensic Res 2:138. doi:10.4172/2157-
7145.1000138
Summary
There is no question that Dr. Murray was irresponsible, medically
negligent, and did not follow the standard of care. However, were his
actions criminal? Did he inject the lethal dose or did Michael Jackson?
It will be up to the legal system and the jury to determine if Dr. Murray
is guilty of involuntary manslaughter. Regardless of the outcome of the
trial, the Michael Jackson death case will forevermore provide a high
profile example of drug addiction, manipulation, and the dangers of
the anesthetic, propofol.
References
1. http://i.cdn.turner.com/cnn/2009/images/08/24/murray.search.warrant.
affadavits.pdf. Accessed September 14, 2011.
2. http://www.thesmokinggun.com/documents/crime/michael-jackson-autopsy-
report.AccessedSeptember 14, 2011.
3. Lepor H (2011) Medical treatment of benign prostatic hyperplasia. Rev Urol
13:20-33.
4. Winawer SJ, Zauber AG, Fletcher RH,Stillman JS, O’brien MJ, et al. (2006)
Guidelines for colonoscopy surveillance after polypectomy: a consensus
update by the US Multi-Society Task Force on Colorectal Cancer and the
American Cancer Society. CA Cancer J Clin 56:143-159.
5. Loscertales J, Congregado M, Jiménez Merchán R (2011) First rib resection
using videothorascopy for the treatment of thoracic outlet syndrome. Arch
Bronconeumol 47: 204-207.
6. Ben-Menachem E (2010) Review article: systemic lupus erythematosus: a
review for anesthesiologists. Anesth Analg 111:665-676.
7. Goldwater PN (2003) Sudden infant death syndrome: a critical review of
approaches to research. Arch Dis Child 88:1095-1100.
8. Marik PE (2004) Propofol: therapeutic indications and side-effects. Curr Pharm
Des 10:3639-3649.
9. Abad-Santos F, Gálvez-Múgica MA, Santos MA, Novalbos J, Gallego-Sandín
S, et al. (2003) Pharmacokinetics and pharmacodynamics of a single bolus of
propofol 2% in healthy volunteers. J Clin Pharmacol 43:397-405.
10. Kirby RR, Colaw JM, Douglas MM (2009) Death from propofol: accident,
suicide, or murder? Anesth Analg 108:1182-1184.
J Forensic Res
ISSN: 2157-7145 JFR, an open access journal
Page 7 of 7
11. Schneider U, Rada D, Rollnik JD, Passie T, Emrich HM (2001) Propofol
dependency after treatment of tension headache. Addict Biol 6: 263-265.
12. Wischmeyer PE, Johnson BR, Wilson JE, Dingmann C, Bachman HM, et al.
(2007) A survey of propofol abuse in academic anesthesia programs. Anesth
Analg 105:1066-1071.
13. Roussin A, Montastruc JL, Lapeyre-Mestre M (2007) Pharmacological and
clinical evidences on the potential for abuse and dependence of propofol: a
review of the literature. Fundam Clin Pharmacol 21:459-466.
14. Soyka M, Schutz CG (1997) Propofol dependency. Addiction 92:1369-1370.
15. Iwersen-Bergmann S, Rösner P, Kühnau HC, Junge M, Schmoldt A (2001)
Death after excessive propofol abuse. Int J Legal Med 114:248-251.
16. Roussin A, Mirepoix M, Lassabe G, Dumestre-Toulet V, Gardette V, et al.
(2006) Death related to a recreational abuse of propofol at therapeutic dose
range. Br J Anaesth. 97:268.
17. Cirimele V, Kintz P, Doray S, Ludes B (2002) Determination of chronic abuse
of the anaesthetic agents midazolam and propofol as demonstrated by hair
analysis. Int J Legal Med 116:54-57.
18. Strehier M, Preuss J, Wollersen H, Madea B (2006) Lethal mixed intoxication
with propofol in a medical layman. Arch Kriminol 217:153–160.
19. Kranioti EF, Mavroforou A, Mylonakis P, Michalodimitrakis M (2007) Lethal self
administration of propofol (Diprivan). A case report and review of the literature.
Forensic Sci Int 167:56-58.
20. Drummer OH (1992) A fatality due to propofol poisoning. J Forensic Sci
37:1186–1189.
21. Chao TC, Lo DS, Chui PP, Koh TH (1994) The first fatal 2,6-di-isopropylphenol
(propofol) poisoning in Singapore: a case report. Forensic Sci Int 66:1-7.
22. Tsai PS, Buerkle H, Huang LT, Lee TC, Yang LC, et al. (1998) Lidocaine
concentrations in plasma and cerebrospinal fluid after systemic bolus
administration in humans. Anesth Analg 87:601-604.
23. Cozanitis DA, Levonen K, Marvola M, Rosenberg PH, Sandholm M (1991)
A comparative study of intravenous and rectal administration of propofol in
piglets. Acta Anaesthesiol Scand 35:575-577.
24. Raoof AA, Augustijns PF, Verbeeck RK (1996) In vivo assessment of intestinal,
hepatic, and pulmonary first pass metabolism of propofol in the rat. Pharm Res
13:891-895.
Submit your next manuscript and get advantages of OMICS
Group submissions
Unique features:
• User friendly/feasible website-translation of your paper to 50 world’s leading languages
• Audio Version of published paper
• Digital articles to share and explore
Special features:
• 200 Open Access Journals
• 15,000 editorial team
• 21 days rapid review process
• Quality and quick editorial, review and publication processing
• Indexing at PubMed (partial), Scopus, DOAJ, EBSCO, Index Copernicus and Google Scholar etc
• Sharing Option: Social Networking Enabled
• Authors, Reviewers and Editors rewarded with online Scientific Credits
• Better discount for your subsequent articles
Submit your manuscript at: http://www.omicsonline.org/submission
Volume 2 • Issue 8 • 1000138